NCQA Behavioral Health Measurement Efforts

OBJECTIVE
To review the role of the National Committee for Quality Assurance (NCQA) in ensuring the quality of care in the managed care setting and identify novel strategies to improve performance rates for Health Plan Employer Data and Information Set (HEDIS) measures, particularly in the area of depression.


SUMMARY
NCQA, by regulating HEDIS measures, sets the standards by which managed care organizations evaluate their performance in providing care for their enrollees. The medication management measure for depression evaluates practitioner contacts and acute and continuation phase treatments for persons treated with an antidepressant. Despite increased detection and management of patients with depression, there is still room for improvement in HEDIS performance rates for this chronic disease.


CONCLUSION
NCQA hopes to improve collaboration among managed care organizations and managed behavioral health organizations In addition, NCQA regularly reevaluates the HEDIS measures using input from panels of experts. Incentive p r o grams for providers who deliver quality care may also help to improve HEDIS performance rates for depression. Research is under way to evaluate the feasibility and re t u rn on investment for pay-for-performance programs in depression.


A B S T R AC T
OBJECTIVE: To review the role of the National Committee for Quality Assurance (NCQA) in ensuring the quality of care in the managed care setting and identify novel strategies to improve performance rates for Health Plan Employer Data and Information Set (HEDIS) measures, particularly in the area of depression. SUMMARY: NCQA, by regulating HEDIS measures, sets the standards by which managed care organizations evaluate their performance in providing care for their enrollees. The medication management measure for depression evaluates practitioner contacts and acute and continuation phase treatments for persons treated with an antidepressant. Despite increased detection and management of patients with depression, there is still room for improvement in HEDIS performance rates for this chronic disease.
CONCLUSION: NCQA hopes to improve collaboration among managed care organizations and managed behavioral health organizations In addition, NCQA regularly reevaluates the HEDIS measures using input from panels of experts. Incentive p r o grams for providers who deliver quality care may also help to improve HEDIS p e r f o rmance rates for depression. Research is under way to evaluate the feasibility and re t u rn on investment for pay-for-p e r f o rmance programs in depression.   phase and provider contacts measures is not as high as the acute phase treatment, and commercial plans do tend to perf o rm better than the Medicaid and Medicare plans on all 3 of the measures. A similar pattern is seen for follow-up rate after mental health hospitalization. If we compare these perf o rmance measures to those for non-mental health conditions, we can see that there is still room for improvement ( Figure 1). In 2003, the average p ro p o rtion of patients who received beta-blockers after a heart attack was high, with a rate of more than 94%. 2 P e rf o rmance rates for other chronic conditions such as asthma and diabetes management are also high compared with those for mental health m e a s u res. There has been little improvement over the past 5 years in any of the antidepressant medication management or follow-up m e a s u res. The question remains as to how we can improve our p e rf o rmance for mental health disorders as we have for non-mental health conditions. Although the measures for antidepressant medication management are not perfect, there are some advantages and good rationale for using them to measure the quality of care for patients with d e p ression. These measures ensure that we identify patients with a new episode of depression who should be treated for a specific length of time. 3 One of the aims for NCQA is to encoura g e collaboration among the managed care organizations and managed behavioral health organizations for the purposes of sharing data.
T h e re are several criticisms to using these measures, including the concern that the denominator, or the number of patients identified with new episodes of depression, is too low and does not reflect actual incidence rates in the population. 4 , 5 A re c e n t i m p rovement was the inclusion of telephone contacts into the optimal provider contacts measure. Of course, plans must be able to track telephone contacts in order to incorporate this number. Other problems that plans still face are the use of samples in p r i m a ry care practice and delays in diagnosis, mainly attributable to stigmatization of the illness in the community. NCQA perf o rms regular reviews of the depression measures in conjunction with its Behavioral Health Measurement Advisory Panel.

■■ Measuring and Encouraging Accountability and Quality of Care
A new direction of NCQA is to incorporate measurement and accountability into provider measurement and re w a rd pro g r a m s . P rograms such as Bridges to Excellence on the East coast and payf o r-p e rf o rmance programs in California aim to measure the quality of care given by providers and to re w a rd them (either the p roviders or medical groups) for good perf o rmance.
T h e re are 2 ways in which provider quality is being measure d in pay-for-p e rf o rmance programs. In the first approach, NCQA integrates administrative data received from the health plans. 6 T h e health plans receive a perf o rmance re p o rt, and the health plans re w a rd those groups based upon high perf o rmance rates. Another a p p roach is to use NCQA' s recognition programs where physi- cians ask to be recognized for the quality of their care . 7 NCQA currently sponsors 3 recognition programs in diabetes, cardiovascular d i s e a s e / s t roke, and practice systems.

Comparing Trends in Behavioral and Nonbehavioral HEDIS Measures
In the content area of practice systems, physicians conduct medical re c o rd reviews or provide information about their practice setting. NCQA conducts surveys and random audits to determ i n e whether the physician or the practice group merits re c o g n i t i o n . Again, HEDIS measures are utilized, and the recognition pro g r a m s a re conducted in partnership with national organizations such as the American Heart Association and the American Diabetes Association. Of course, these programs are strictly voluntary and only those physicians or practice groups who meet the re c o g n i t i o n t h resholds are publicly re p o rt e d .
T h e re are a growing number of organizations that are using these recognition programs to recognize physicians. For example, an employer consortium, the Bridges to Excellence program, pays re w a rds to providers based on NCQA' s recognition pro g r a m s . 8 R e c e n t l y, NCQA received a grant from the Robert Wood Johnson Foundation to identify and test the feasibility of perf o rm a n c e m e a s u res for depression that would be suitable for pay for p e rf o rmance pro g r a m s . 9

■ ■ Conclusion
The identification and treatment of depression has improved with education, care management programs, and better utilization of a n t i d e p ressant medications. Future directions for NCQA with these projects include identifying potential indicators for depre s s i o n that assess the stru c t u re and process of depression care. We plan to incorporate outcome measures in order to determine whether patients improve clinically. We hope to meet the goals of NCQA in developing measures to improve quality of care and incre a s e accountability at all levels of health care .

DISCLOSURES
The author received an honorarium for participation in the symposium upon which this article is based. She discloses no potential bias or conflict of intere s t relating to this article.